Unit 10 Diabetes General Treatment Principles

Diabetes: General
Treatment Principles
Mikael D. Jones, Pharm.D., BCPS
Clinical Assistant Professor
UK College of Pharmacy
UK College of Nursing
Introduction
 Nearly 16 Million Americans are affected
by DM
 Estimated that approximately 5.4 million
adults in the US have undiagnosed DM
Endocrine Pancreas
 Islets of Langerhans
 Scattered in exocrine
pancreas
 Made up of 4 cell
types
 Distribution of cell
type varies with
region of pancreas
Percentage of Islet
Volume
Anterior
head, Posterior Secretory
Cell Type Body, Tail Head Products
α cell 10% <0.5% Glucagon
β cell 70-80% 15-20% Insulin,

Amylin
 cell 3-5% <1% Somatostat
in
F cell <2% 80-85% Pancreatic
Polypeptide
Diabetes Pathophysiology
 Diabetes Mellitus is the major disease
affecting the pancreas.
 DM occurs when there is insufficient
secretion of insulin from the pancreas, or
when target tissues do not respond to
circulating insulin in the appropriate
manner.
 Hyperglycemia is a symptom of underlying
problem
Types of Diabetes
 Type 1
 Type 2
 Gestational
 Secondary
Types of Diabetes
 Type 1  ß-cell destruction usually leading
to absolute insulin deficiency
 Type 2  insulin resistance or insulin

secretory defect
Type 1 Characteristics
 Usually adolescent onset
 Little to no C-peptide
 Autoimmune process
 Weak family history
 Obesity uncommon
 Diabetic Ketoacidosis (DKA) often present
 Insulin mandatory although diet and exercise
also play key roles in therapy
Type 1 Signs and Symptoms
 Frequent urination (polyuria & nocturia)
 Unusual thirst (polydypsia)
 Extreme hunger
 Unusual weight loss
 Extreme fatigue
 Irritability
 Ketoacidosis
Type 2 Characteristics
 Usually adult onset
 Varying insulin levels, hyperinsulinemia
not uncommon
 Insulin resistance
 Strong family history
 Obesity common
 DKA rare
Type 2 Symptoms
 Frequent infections
 Blurred vision
 Cuts/bruises slow to heal
 Tingling/numbness in hands or feet
 Recurring skin, gum, or bladder infections
 Any of the Type 1 signs
 Often no symptoms occur
Type 2 Risk Factors
 Family history of diabetes (parents or
siblings with diabetes)
 Obesity (>20% over desired body weight
or BMI >27 kg/m2)
 Race/ethnicity (African-Americans,
Hispanic-Americans, Native Americans,
Asian-Americans, Pacific Islanders)
 Age >45 years
Type 2 Risk Factors
 Previously identified IFG (Impaired fasting
glucose) or IGT (Impaired glucose tolerance)
 Now called pre-diabetes
 Hypertension (>140/90 mmHg in adults)
 HDL cholesterol level <40 mg/dL &/or a
triglyceride level >250 mg/dL
 History of GDM or delivery of babies over 9
lbs.
Chronic Complications of
DM
 macrovascular disease
 microvascular disease
 ocular disease
 neuropathy
 nephropathy
Management of Diabetes
 Primary control
 diet
 exercise
 self-monitored blood glucose
 medications
 other monitoring/testing
Management of Diabetes
 Controlling complications and target organ
damage
 blood glucose/glycosylated hemoglobin
 blood pressure
 dyslipidemia
 weight management
 smoking
 dental/foot/eye care
 vaccinations
DCCT
 Diabetes Control & Complications Trial
 Compared conventional vs. Intensive
insulin therapies
 Conventional: 1-2 insulin injections daily &
QD blood glucose monitoring
 Intensive: 3+ insulin injections daily or
insulin pump & TID to QID blood glucose
monitoring
Results of DCCT
 Intensive insulin treatment resulted in:
– 63% reduction in sustained retinopathy
– 26% reduction in macular edema
– 40-50% reduction in clinical neuropathy at 5
years
 Results demonstrate the value of
monitoring BGL 3-4 times daily &
achieving tight control of BGL
United Kingdom Prospective
Diabetes Study (UKPDS)
 Largest & longest study on Type 2 diabetic
patients performed to date
 Established that retinopathy, nephropathy, &
possibly neuropathy are benefited by lowering
BGL with intensive therapy to achieve median
HbA1c of < 7%
 Lowering BP to mean of 144/82 mmHg
significantly reduced stroke, diabetes-related
deaths, heart failure, microvascular
complications, & visual loss
Specific Treatments For DM
 Type 2
 Diet and Exercise
 Medications
 Insulin
 Type 1
 Insulin mandatory
 diet and exercise important components of
management
Diet
 ADA diet goals:
 adequate calories for weight control
 regularly scheduled meals and snacks
 normalize glucose and lipid levels
 minimize extreme variations in blood glucose
levels
 limit intake of simple sugars, especially if
weight is not in control

Diet
 Calories:
 reduced calorie diet for Type 2 that are
overweight or obese
 sufficient calories in Type 1 to maintain
normal weight
 Meal plans:
– Food pyramid - first step in meal planning
– Healthy food choices
– Exchange lists?
Diet
 Suggested content of diet based on total
calories
 10% protein (0.8 mg/kg/day)
 30% total fat (no more than 10% saturated
fat)
 60% carbohydrates
Exercise
 Important for overall general good health
 Use in type 2 DM
 helps in treatment by increasing insulin efficiency
and promoting weight loss
 important preventative measure in high risk patients
 decreases need for oral agents and insulin tx
 Current recommendation
 30 minutes of moderate exercise on most days of the
week
Exercise
 Use in type 1 DM
 increases insulin efficiency
 important to have regularly scheduled
sessions
 monitor blood glucose before and after
exercise to determine effects
 avoid “spurts” or “bursts” of exercise, may
lead to hypoglycemic events
 Carry or have snack prior to exercise
Standards of Medical Care
Glycemic Goals of Therapy
Normal Goal
Preprandial plasma <100 mg/dL 80-130 mg/dL

glucose
Postprandial plasma <140 mg/dL <180 mg/dL

glucose
A1c (%) 4-6% <7%*
Note: Normal vs. Goals!

should be tailored based on age, co-morbidities, history of diabetes con
Diabetes Monitoring
 Blood
 glucose
 hemoglobin A1c
 fructosamine
 lipid profile
 creatinine
 BUN
Diabetes Monitoring
 Urine
 ketones (Type 1)
 glucose
 protein
 Weight
 Blood Pressure
Problems Associated with
Urine Glucose Testing
 Not easily interpreted; some test are
qualitative not quantitative
 Potential for false positive readings
depending on test used
 Lack of direct correlation between urine
glucose & blood glucose levels
 Results are technique-dependent
Frequency of Blood Glucose
Monitoring
 Minimum Recommendations
 Diet/Exercise or oral meds
 Range from 2-3 times per day to 2 -3 days per week
 Fixed-dose insulin
 Range from 3-4 times per day to 3 days per week
(including 1 weekend day)
 Intensive insulin therapy
 3-4 times per day every day
 3 a.m. measurement weekly
Frequency of Blood Glucose
Monitoring
 Additional measurements needed during:
 illness
 change in exercise habits
 travel
 change in treatment plan
 symptoms of hypo/hyperglycemia
Factors Affecting Accuracy of
Blood Glucose Tests
 User variability  Extreme environmental
temperature
 Hematocrit >60% or <25%
 Hypoxia
 Defective reagent strips
 temperature, moisture,
 Altitude
time  Humidity
 lot-to-lot variance  Uric Acid
 Very High TG and/or  Ascorbic Acid
cholesterol  Improper cleaning and
maintenance
Glycosylated Hemoglobin
(HbA1c)
 Formed when glucose reacts with hemoglobin
(concentration-dependent reaction)
 Usually constitutes 4-6% of total hemoglobin
 Level reflects the average blood glucose over 3
months
 Level can be drawn any time of day, regardless
of meals
 Best indicator of overall degree of glycemic
control
Monitoring-Hemoglobin A1c
 Gold standard for monitoring long-term
control
 Reflects glycemic control over past 2-3
months
 Should be performed every 3-6 months
 3 months if therapy has changed or goals
not met
 6 months if meeting treatment goals
HbA1c Goals of Therapy
 Reported as a percentage of total
hemoglobin content
– 4.5-6% = Normal
– < 7% = Goal
– 7-8% = Fair Control
– 8-9.5% = Fair to poor control Control
– > 9.5% = Poor Control
A1c Relationship to FPG
A1c % Mean Plasma Glucose (mg/dL)
6 126
7 154
8 183
9 212
10 240
11 269
12 298
Interpreting HbA1c Levels
 Always consider the time frame
– daily glucose values provide a “snapshot”
– quarterly HbA1c values provide the “big
picture” of glycemic control
– patient may be in good control over the past
2 weeks (from BG results), but HbA1c value
elevated from “memory” of elevated levels in
weeks prior
Interpreting HbA1c Levels
 Must experience hyperglycemia for 2-4

weeks before HbA1c will rise significantly
 Control which has gone from good to
poor over a few weeks may not look bad
using HbA1c therefore daily monitoring &
recording is necessary
 HbA1c >8% almost always warrants
changes in therapy
Conditions Affecting Results
 Anything affecting the average life span of
the RBC can cause misleading HbA1c
results, including:
– bleeding
– hemolysis
– sickle cell anemia
Self-management Education
 Compliance is a key issue:
 Scottish study of 3,000 type 2 diabetics over a
3 year period showed just 31% of patients

taking sulfonylureas and 34% of those taking
metformin refilled their prescriptions often
enough to take 90% of the scheduled doses
 Of those taking both only 13% obtained refills
often enough for 90 % of the scheduled doses

to be taken
Self-management Education
 How to use glucose monitor
 How to clean monitor
 How to interpret results
 When to take readings
 Importance of keeping diary
 Blood glucose level and A1c goals
Patient Education Topics
 Importance of:
 nutrition(food plans, vitamins, minerals)
 regular exercise
 foot care with yearly comprehensive foot
exam
 yearly eye exams
Patient Education Topics
 DM & Dyslipidemia
 DM & HTN
 DM & Smoking
 DM & Immunization
 DM & ASA use

Foot Care
 There is an increased risk of ulcers and
amputations in the following persons:
 diabetes > 10 yrs.
 male
 poor glucose control
 end organ damage present already

Foot Care
 94% of 353 diabetic’s charts reviewed showed no

foot exam during the following year
 Current recommendation is a thorough foot exam
at least yearly
 assess protective sensation, foot structure, vascular
status and skin integrity
 those with neuropathy should have a visual inspection
of their feet at each office visit

Eye Exams
 After 20 years, nearly all type 1 and 60% of
type 2 diabetics will have some retinopathy
 Current recommendation is 1st retinal exam
upon diagnosis with a yearly follow-up
 Of those 353 diabetics 74% had no
verification of a retinal exam or
ophthalmologic referral in the previous year
DM & Dyslipidemia
 Type 2 diabetics have a 2-4 fold increase
risk of coronary heart disease (CHD)
 The most common pattern of dyslipidemia
is  TGs and  HDL while LDL seem to be
similar to non-diabetics
 Weight loss and exercise will  TGs and 
HDL without need for drug therapy
 Also  saturated fats in diet
DM & HTN
 HTN contributes to the development and progression of
chronic complications of DM
 Decreasing BP will slow the rate of progression of
neuropathy, reduce CV disease and cerebrovascular
complications
 Goal BP is <140/90 mmHg
 Consider ACEI or ARB as first line
 Renal protective
 Recent study indicated that only 12% of patients with DM
and HTN were reaching treatment goals

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Diabetes: General

β cell 70-80% 15-20% Insulin,

 Type 2  insulin resistance or insulin

 self-monitored blood glucose

 normalize glucose and lipid levels

 minimize extreme variations in blood glucose

weight is not in control

 decreases need for oral agents and insulin tx

Preprandial plasma <100 mg/dL 80-130 mg/dL

Postprandial plasma <140 mg/dL <180 mg/dL

A1c (%) 4-6% <7%*

Note: Normal vs. Goals!

 change in treatment plan

 Must experience hyperglycemia for 2-4

3 year period showed just 31% of patients

often enough for 90 % of the scheduled doses

 foot care with yearly comprehensive foot

 DM & ASA use

 poor glucose control

 end organ damage present already

 94% of 353 diabetic’s charts reviewed showed no

of their feet at each office visit

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